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Preventing Surgical Complications
Presenter:
Preventing Surgical Complications
1000 Lives Campaign
To save 1,000 lives and to avoid
50,000 episodes of harm in Welsh
healthcare between 21 April 2008
and 21 April 2010.
Preventing Surgical Complications
Content Areas
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•
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Improving leadership for quality
Reducing healthcare associated infections
Improving critical care*
Improving medicines management
Reducing surgical complications*
Improving general medical and surgical care
• Development Sites
*Trusts Only
Preventing Surgical Complications
Hospital blunders 'kill
90,000 patients'
Rebecca Smith, Medical Editor,
Daily Telegraph 29.11.07
More than 90,000
patients die and
almost one million
are harmed each
year because of
hospital blunders,
research suggests.
Preventing Surgical Complications
Researchers found that up to half of
the mistakes made were preventable
Preventing Surgical
Complications
• Preventing post operative wound (surgical site)
infections
–
–
–
–
Antibiotics
Hair removal
Glycaemic control
Normothermia
• Creating a team culture
– Team briefing
• Preventing cardio vascular complications
– DVT prophylaxis
– Beta blockers
Preventing Surgical Complications
Evidence
Patients who develop post operative wound
infections
• are twice as likely to die as other postoperative
patients.
• Up to 60% more likely to spend time in an
intensive care unit.
• If it develops after discharge, they’re five times
more likely to be readmitted to the hospital.
Preventing Surgical Complications
Whole surgical pathway
Pre Operative Assessment
Surgical ward / Day care ward
Anaesthetic room
Theatres
Recovery
Surgical Wards
Primary Care
Preventing Surgical Complications
Appropriate use of
antibiotics
• Antibiotics within 1 hour before surgical
incision*
• Prophylactic antibiotic agent consistent with
locally determined guidelines
• Discontinuation of prophylactic antibiotics
within 24 hours of surgery
*Due to the longer infusion time required for vancomycin, it is acceptable to
start this antibiotic (e.g., when indicated because of beta-lactam allergy
or high prevalence of MRSA) within 2 hours prior to incision.
Preventing Surgical Complications
Antibiotics cont.
Exceptions:
• within two hours if patient receiving vancomycin,
• If surgery is being carried out with tourniquet control,
all antibiotic administration must be completed before
the tourniquet is inflated and within one hour prior to
surgical incision.
• Women undergoing caesarean section should
receive the antibiotic as soon as the umbilical cord is
clamped.
Preventing Surgical Complications
Evidence
• Appropriate antibiotic selection occurred in 92.6% of cases;
• Antibiotics were given within one hour of incision time to
55.7% of patients; and
• Prophylactic antibiotics were discontinued within 24 hours of
surgery end time for only 40.7% of patients. (Bratzler 2005)
• Patients who received the first dose either more than 60
minutes before incision or after incision had higher rates of
POWI, and the further the dose time was from incision, the
greater the rate of POWI (Classen 1992).
Preventing Surgical Complications
Use Recommended
Hair Removal Methods
Only electric shavers to be used to
remove hair at the site of incision.
Preventing Surgical Complications
Evidence
• Three trials involving 3193 people compared shaving
with clipping and found that there were statistically
significantly more SSIs when people were shaved
rather than clipped
• Seven trials involving 1213 people compared shaving
with removing hair using a depilatory cream and
• found that there were statistically significantly more
SSIs when people were shaved than when a cream
was used (Tanner 2006)
Preventing Surgical Complications
Maintenance of
Postoperative Glycaemic
Control
• All diabetic patients (whether insulin or tablet controlled) should
have capillary glucose monitoring instituted at a minimum
frequency of 4 times daily prior to transfer to the operating theatre.
• All diabetic patients should have their management reviewed to
ensure tight glycaemic control is attained.
• All surgical units should have procedures in place to identify and
manage all patients with diabetes. This will include access to
appropriately trained diabetes specialist teams.
*NOTE that, for the purposes of this campaign, “tight glucose control” is defined
as serum glucose levels between 5.0-10.0 mmol/l , throughout
postoperative period.
Preventing Surgical Complications
Hypothermia
Preventing Surgical Complications
Maintenance of Postoperative
Normothermia
• Patients are risk assessed for the potential to develop
inadvertent hypothermia during surgery (documented).
• Patients with a core temperature of less than 36oC pre
operatively do not commence their anaesthesia and surgery
until they have been warmed using forced warm air. Active
warming should continue throughout the procedure.
• All patients at risk and / or with surgery anticipated to last >30
minutes, are warmed intra operatively using forced warm air.*
*If this is not a practical intervention e.g. exposed surface area too extensive to allow
forced warm air, then evidence from a small study suggests that electric blankets
underneath the patient will maintain core temperature (Just 2003).
Preventing Surgical Complications
Maintenance of Postoperative
Normothermia - cont
• All patients routinely have their temperature monitored; in the
hour before surgery, before induction, every 30 minutes during
surgery, on arrival in the recovery room and every 15 minutes
during the recovery period.
• Healthcare professionals should ensure that intravenous fluids
(500 ml or more) and blood products are warmed to 37°C
using an appropriate fluid warming device.
• Patients who arrive in recovery with a temperature less than
36oC should be warmed using forced warm air.
Preventing Surgical Complications
Maintenance of Postoperative
Normothermia – pre
assessment
In the perioperative period, ideally during the patient’s pre
operative assessment appointments, patients who have the
following risks should be identified as being at higher risk of
developing hypothermia perioperatively:
- ASA grade greater than I (the higher the grade, the greater
the risk)
− undergoing combined general and regional anaesthesia
− undergoing major or intermediate surgery
− at risk of cardiovascular complications (for example, age
over 50 years).
Preventing Surgical Complications
Evidence – favour
treatment
• Two studies recorded the occurrence of cardiac events after
surgery.
• Four studies examined the need for blood transfusion between
groups.
• Two studies recorded the incidence of postoperative wound
infection.
• One study recorded the occurrence of pressure damage. The
results of this study did not reach statistical significance, but
the author points out that warming of patients did reduce the
risk of pressure ulcer occurrence by half, which is clinically
significant.
Preventing Surgical Complications
Team briefing at start
of list
Some of the ways in which team briefings can be developed
are:
• Allocating five minutes before the start of the operating list
where the core members of the team e.g. surgeon, scrub
nurse, circulating nurse, ODP and anaesthetist can meet to
discuss the requirements of that operating list and any
safety concerns.
• Identify in advance a list of safety issues for discussion e.g.
patient allergies, anticipated complications etc., potentially
using a structured checklist
• Using a de-briefing session at the end of the operating list to
review any issues raised, answer concerns or discuss
incidents.
Preventing Surgical Complications
Aims of interventions
Preventing Surgical Complications
Evidence
• increased employee satisfaction, improved
perceptions of safety climate,
• Reduction in potential for wrong site surgery and
• better interprofessional empathy and understanding
(Defontes & Surbida, 2003).
• increased confidence
• across the OT team to speak up when spotting
potential problems (Burke 2005)
Preventing Surgical Complications
Identifying patients at risk
and provide appropriate
DVT prophylaxis
• Documented DVT risk assessment of every surgical
patient
• All high-risk surgical/orthopaedic patients should receive
graduated compression stockings combined with
heparins.
• Intermediate-risk surgical patients considered for
graduated compression stockings combined with
heparins.
• Low-risk surgical patients do not require specific
prophylaxis other than early mobilisation, unless other
factors are present which increase overall risk and thus
place them in intermediate or high-risk categories
Preventing Surgical Complications
Where can we make the most
difference to mortality?
•
20% of patients undergoing major surgery experience a DVT. From data
available on PEDW there were 14,206 major operations .
14202/100 * 20 = 2841 for one year.
•
In 2006/7 there were 9579 hip and knee replacements. Between 45-51% of
orthopaedic patients suffer a DVT (NICE 2007).
9579/100 * 45 = 4310
9579/100* 51 = 4885
•
Estimated that the risk of pulmonary embolism following high-risk surgery
to be up to 5% in the highest risk groups (orthopaedics)
9579/100 * 5 = 478
Preventing Surgical Complications
Continue beta blockers for
patients admitted on beta
blockers
Beta blockers should be continued in
patients undergoing surgery who are
receiving them to treat angina,
symptomatic arrhythmias, hypertension,
or other ACC/AHA class I guideline
indicators.
Preventing Surgical Complications
Evidence
• continuous beta-blocker use remained significantly
associated with a lower 1-year mortality than among
nonusers (Hoeks et al 2007)
• Mortality in the patients who had beta blockers
discontinued postoperatively (50%) was significantly
greater than in the patients in whom beta blockers
were continued (Shammash et al 2001)
Preventing Surgical Complications
The PDSA Cycle
Act
Plan
Study Do
Preventing Surgical Complications
PDSA
• Small changes, one patient, one list, one team
• Measure – did it work, if not try something
different
• Spread if did work
• Identify a pilot population
• Measure
• Are you already doing it? – measure
compliance
Preventing Surgical Complications
Finally
Contact details
[email protected]
Content Specialist
Preventing Surgical Complications